Older adults with HIV are falling through the clinical cracks, according to the results of a recent study conducted by researchers at the Yale University School of Medicine and Whitman-Walker Health. The study showed that almost two-thirds of older adults who were diagnosed with HIV at a Connecticut clinic were already at an advanced stage of disease progression, and that those who enter late to care may take longer to achieve an undetectable viral load once they initiate antiretroviral therapy (ART).
These findings join prior evidence in underscoring the need for primary care providers to step up their game when it comes to HIV testing, treatment, and prevention for older adults.
“Health care providers need to treat HIV testing as routine whenever the diagnosis is not immediately apparent, regardless of age,” said longtime HIV epidemiologist Amy Justice, M.D., Ph.D., a professor at the Yale School of Medicine and Yale School of Public Health. “As the prevalence of HIV among those over 65 years of age continues to rise, incidence will also likely increase. There is a strong misperception that older people are not at risk. Further, older people may be reticent to report risk behaviors. Instead, HIV testing should be offered as a routine means of identifying a potentially treatable condition,” said Justice.
In the current study, Faiza Yasin, M.D., M.H.S., and colleagues conducted a retrospective review of medical records of 188 people with newly diagnosed HIV who received care at the Nathan Smith Clinic between January 2010 and December 2019. The researchers collected data on patients’ demographics, HIV staging, and response to ART as measured by HIV viral suppression at 12 weeks (HIV RNA fewer than 50 copies/mL). They compared characteristics and outcomes of those 50 years of age or older (n=49) to those younger than 50 years old (n=139) using bivariate analysis.
Of all those newly diagnosed and entering care, the study found that 65.3% of patients aged 50 or older entered care with clinical AIDS as defined by the Centers for Disease Control and Prevention (i.e., CD4 count lower than 200 or the presence of an AIDS-defining illness), compared to only 30.9% of the younger participants, a statistically significant difference (P < .0001).
The 50-and-over group also had a delayed time to viral suppression, with only 59.2% achieving viral suppression 12 weeks after starting ART, compared to 64% in the younger group, although this finding did not reach statistical significance.
Those in the older group also had a significantly lower mean CD4 count at time of diagnosis compared to the younger group (263.3 vs. 398.5 cells/µL, P = .01). In addition, the older group fared worse in terms of immune reconstitution, with a smaller (but not significantly) increase in CD4 count (130 cells/µL) compared to the younger group (167 cells/µL). Viral load at time of diagnosis did not differ significantly between the two age groups.
These results suggest that older adults at risk for HIV in this geographic area were not getting regular, routine testing; in turn, those who acquired HIV were not finding out about their status promptly, and thus were not getting into care until later in the course of infection, a situation which undermines successful long-term outcomes once they initiate ART.
Why Are So Many Older People Still Presenting With HIV Late?
The factors leading to older adults with HIV presenting late to care are no secret, and they occur at a range of levels, according to Matthew J. Mimiaga, Sc.D., M.P.H., M.A., director of the UCLA Center for LGBTQ Advocacy, Research, and Health. Mimiaga identified several of these factors, including:
- Structural: affordability of health insurance, cost of prescription medications, and access to culturally competent clinical care.
Societal: stigma, ageism, homophobia, and discrimination (which especially impact people of color and ethnic minorities).
Provider: misdiagnosed HIV, or the mistaken belief that older gay and bisexual men are not sexually active.
Individual: inaccurate self-perception of HIV risk, internalized homophobia, relationship status and dynamics (e.g., intimate partner violence), and psychosocial problems (e.g., depression or substance use).
While too many older adults living with HIV are missing out on the care and treatment they need, the bottleneck would appear to be primarily at the testing part of the HIV care continuum, rather than the treatment part. “The problem is not so much getting them plugged into care once they are identified as positive,” said Justice. “Older people are often more comfortable with the health care system and more able to adhere to medication than younger individuals. The problem is making the diagnosis in a timely manner.”
While the study by Yasin and colleagues emphasizes gaps in HIV testing and treatment for older adults, according to the Centers for Disease Control and Prevention (CDC), older adults face particular HIV-prevention challenges: Although they visit their doctors more frequently than younger people, they are less likely to discuss their sexual activity or drug use with their provider. Providers, in turn, may fail to ask their older patients about these issues, or to test them for HIV on a routine basis. Moreover, as Mimiaga noted, older people may not consider themselves to be at risk for HIV, may be embarrassed to discuss sex with their doctor, or may mistake HIV symptoms for aspects of ordinary aging. In addition, like younger people, older adults may lack knowledge about HIV risk factors, such as having multiple sex partners, and may be less likely to use a condom or other prevention options.
In a prior study among men who have sex with men (MSM) in Philadelphia, of 1,043 HIV-negative MSM, 70.2% had an HIV test in the preceding twelve months. However, those 45 years of age or older, and those with Medicaid, were significantly less likely to have had an HIV test. While 80% of participants had seen a medical provider in the past year, only 50% had been offered an HIV test. These findings underscore the importance of optimizing HIV testing through increasing awareness and uptake of pre-exposure prophylaxis (PrEP), especially among older MSM.
Expanding PrEP among older adults, however, may not be as simple as getting primary care providers to educate their patients or recommend the HIV prevention regimen. “An important complicating factor for older individuals will be polypharmacy,” said Justice. “PrEP may interact with other medications. We need better means of identifying these interactions and prioritizing medications. PrEP may not be the best answer for everyone in this group.”
The study by Yasin and colleagues shines a light on the problem of late HIV diagnosis among older adults as an ongoing public health problem that remains inadequately addressed. “As per the CDC recommendations, every adult should be tested for HIV at least once in their lifetime, and annually if at risk,” said Lydia Aoun-Barakat, M.D., an associate professor at the Yale School of Medicine, a co-author of the study, and the medical director of the clinic where the study was conducted. “In addition, we should implement the test and treat approach that … improves linkage to care, retention in care, and viral suppression, thus decreasing HIV transmission.”
Aoun-Barakat added that, if we truly want to improve our ability to diagnose older people with HIV and enter them into care, the health care community also needs to get more comfortable with addressing their sexual health. “For those who are at risk for HIV, we should offer PrEP,” she said. “We need to normalize HIV and sexuality, and remove the stigma associated with both.”